Obamacare Is Experimenting On Us (Does That Make Us Frankenstein Or Fusilli?)

Obamacare is a large, unwieldy law. Despite its complexity, most people are familiar with its most important elements. They know it created a marketplace where people can shop for healthcare insurance; many are even aware that the cost of that insurance is subsidized for people with lower incomes. Others realize that Obamacare encouraged states to expand Medicaid. And of course, almost everyone has heard of the now defunct individual mandate which required people to purchase insurance or face a tax penalty.

But most Americans probably aren’t aware of what, in the long run, could turn out to be the most impactful part of the Affordable Care Act. The crafters of the ACA recognized that the science of healthcare delivery hadn’t advanced far enough to identify the best ways to improve healthcare quality while lowering healthcare costs. So, lawmakers set a slew of experiments in motion, designed to test ways of accomplishing these goals.

Results of those experiments have been coming out of the lab lately, raising the question of what kind of creatures Obamacare has been creating—are they like Frankenstein’s monster, terrifying but misunderstood? Are they like Edward Scissorhands, loved by suburban moms until they realize how dangerous he is? Or are they like a less renowned creature—Fusilli Jerry, the pasta stick figure that Kramer made for Jerry Seinfeld on that eponymous 1990s sitcom?

I side with the latter, because I view the Obamacare experiments as a type of pasta-flinging exercise. People at CMMI, the federal agency in charge of running these experiments, have been cooking up a bunch of ideas, throwing them into a pot, pulling them out one at a time, and then flinging them against a metaphorical wall to see which ones stick—which ones are ready for public consumption. Some relatively recent studies serve as a good introduction to what Obamacare has been cooking up for the American healthcare system.

Some of the Obamacare pasta has bounced off the wall, with little evidence it will be palatable anytime soon. For example, in 2011 Medicare began a Value-Based Purchasing Program with hospitals, or as the cool kids call it, VBP. Among other things, the VBP program rewarded hospitals for either receiving high patient satisfaction scores, or for improving their satisfaction ratings compared to previous years. Following the implementation of the program, patient satisfaction increased in VBP hospitals. However, satisfaction also increased in hospitals that didn’t participate in VBP, at the same rate over the same period of time. And for both kinds of hospitals, the increases appear to simply reflect continuation of a trend that preceded the VBP program:

In short, judged by patient satisfaction, the VBP program appears to be a failure.

But not all of the Obamacare experiments have been undercooked. Consider the Hospital Readmissions Reduction Program. Started in 2010, the program was designed to encourage health care providers to take better care of patients after they were discharged from the hospital, so their illnesses wouldn’t simply relapse and land them back on 5 West. In the program, Medicare calculates the risk that any patient will require rehospitalization—super sick patients, for example, may need readmission even if receiving optimal care. Medicare penalizes hospitals when their readmission rate is higher than expected. An article from the Annals of Internal Medicine illustrates the risk-standardized readmission rates—RSRR—for hospitals in the ten years before the Medicare program and then in the three years after the program started. The figure shows readmission rates plummeting, especially for the lowest performing hospitals (the top line).

Skeptics may assert that these reductions are fake findings, that hospitals haven’t improved the quality of care they provide but, instead, have merely upcoded patients’ diagnoses and comorbidities to cause Medicare to predict a higher readmission rate.

But another recent study suggest that readmission rates do reflect the quality of hospital care. A team led by Harlan Krumholz, a Yale cardiologist and health policy guru, looked at what happened to patients who were admitted to more than one hospital over the course of a year. They discovered that those patients were less likely to require readmission in the thirty days following admission to a high-performing hospital than a low-performing one. Because the study followed the same patients across hospitals, it eliminates the role of upcoding in determining readmission rates.

No matter what happens to the ACA marketplace, Medicaid expansion, or other elements of Obamacare, these experiments are likely to continue. Some are still too al dente for my taste. But the idea of testing ways to improve American healthcare? Molto buono!